Provider Demographics
NPI:1801139613
Name:WARDELL, NICOLE K (LCSW)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:K
Last Name:WARDELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1560 N MAIN ST APT C7
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-2085
Mailing Address - Country:US
Mailing Address - Phone:307-272-0289
Mailing Address - Fax:
Practice Address - Street 1:275 N 300 W STE 404
Practice Address - Street 2:
Practice Address - City:KAYSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84037-1880
Practice Address - Country:US
Practice Address - Phone:801-614-5866
Practice Address - Fax:801-825-1162
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-29
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11522297-35011041C0700X
UT11522297-3506101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty